THREATS AND RESPONSES: THE DOCTORS

THREATS AND RESPONSES: THE DOCTORS; Mental Health: The Profession Tests Its Limits

Published: September 11, 2002

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Yet the federal government's disaster planning is focused almost entirely on short-term relief. The emergency money that FEMA provides to states, for example, normally cannot be used for anything except crisis counseling.

In an era of managed care, few health insurance policies cover long-term mental health treatment. And few people can afford to pay for such care out of their pockets.

Aware of these problems, two large charities, the September 11th Fund and the Red Cross, announced last month that they would reimburse anyone directly affected by Sept. 11 for the cost of longer-term therapy. Other, smaller foundations have also given out grants for more extended treatment. In August, FEMA gave New York state officials permission to use the relief money provided by the agency to pay for more extended treatment.

Yet even with such resources available and widely publicized, it is still a challenge for mental health officials to get the services to the people who most need them.

Lifenet's calls have increased greatly, but they represent a fraction of those people that surveys suggest are still having serious problems. Therapists in private practice report little increase in their patient loads. The New York Academy of Medicine researchers found only a very slight bump in the number of New Yorkers who reported having seen a mental health professional -- from 16.9 percent before the attacks to 19.4 percent five to eight weeks afterward. People with post-traumatic stress disorder or depression were more likely to have increased their use of mental health services, the survey found.

''But the increase was not clinically significant,'' said Dr. Joseph A. Boscarino, a senior scientist at the academy. ''We expected higher use rates.''

Some family members of those who died say they have joined support groups or found therapists on their own.

Jennifer Jacobs, whose husband, Jason, died in the World Trade Center, said she was aware of the free counseling offered by Project Liberty and the Red Cross, as well as by her husband's company. But she preferred, she said, to find ''my own person.''

For some people, the stigma attached to psychiatric treatment may still stand as a barrier, despite the widespread acknowledgment that the events of Sept. 11 carried enormous emotional power. Others say they have received all the help they need from family members and friends. Still others, said Dr. Draper, say they are just not ready.

The Great Unknown

Looking for Answers, And Right Questions

Faced with a traumatic event of mammoth proportions, government officials and the public at large turned to experts for guidance. Their knowledge, gained from studies of natural disasters, acts of terrorism and other forms of violence, proved enormously helpful.

But there were some questions researchers could not answer.

They could not say for certain how many people would suffer long-lasting problems or what those problems would be.

They could not predict precisely who would fall ill, although they could name some factors -- proximity, a history of trauma, a feeling of unreality during the event -- that seemed to make people more vulnerable.

Nor could the experts agree on which treatments were effective, though they could identify the techniques -- cognitive behavioral therapies and antidepressants -- that had the most empirical backing. Many other treatments had simply not been tested.

''There's zero data on what kind of treatments work specifically for victims of terrorism, in the context of living with ongoing threat,'' said Dr. Randall Marshall, a psychiatrist at Columbia and the director of trauma studies and services at the New York State Psychiatric Institute.

In other areas, there was not only a lack of consensus but active debate, like that over a popular type of debriefing. Some experts argued that the practice, which involved a single session of group therapy, was ineffective and could even slow recovery for some people. Others defended the debriefing method.

Last week, researchers in the Netherlands added to the debate, publishing an analysis of existing studies. They found that while people who underwent the debriefing session often said they found it helpful, there was no evidence that it prevented the development of post-traumatic stress disorder.

The only way to resolve such disputes is to do more studies, experts say. Sept. 11, with all its horrors, offered an enormous research opportunity, and some experts say the work now being done will advance knowledge substantially.

''Frankly, I think we will have more definitive data about the impact of this disaster than has ever been the case,'' Mr. Felton of the state mental health office said.

Studies conducted in the last year have already revised some assumptions, challenging, for example, the way most investigators have defined exposure to a traumatic event.

''Being directly affected is in some senses in the eye of the beholder,'' said Dr. Schlenger of the Research Triangle Institute. ''If you lived across from the World Trade Center, you were obviously directly affected. What's less obvious is that if you were sitting in Des Moines and your granddaughter just started working in the World Trade Center, that's a pretty direct exposure.''

A survey by Dr. Schlenger and his colleagues, published in August, also raised questions about television's effects.